Common Eyelid problems related to dry eye disease, Part 3: The eyelid “outtie.”
Part 3: When eyelids turn in the wrong direction: Ectropion = turns out
Eyelids are critical to the wellbeing of the eye, as they provide the “heartbeat” that circulates the tears over the living surface of the eye, as well as protecting and supporting the eye in its socket. They are made of a tough “skeleton” (called the tarsus, or tarsal plate), with an inner lining of conjunctiva (the smooth, moist membrane that also covers the white part of the eye) and an outer layer of muscles and skin. There are tough ligaments that connect the lids to the eye socket bones at the inner and outer corners – and suspend the lids a bit like a “hammock.” Normally, the muscles controlling and supporting the lid activities of a blink, also help to “balance” that “hammock,” so it stays upright and in good alignment with the eyeball. Unfortunately, age, injury, surgeries, sun, tumors, nerve and muscle weaknesses and genetics can all contribute to an “imbalance” of the muscles, resulting in a “tipping” or turning of the “hammock.” This can lead to an outward turning (Ectropion) or inward turning (Entropion) – and each has expected (and sometimes unexpected) consequences. Below is an example of ectropion:
Involutional ectropion of the left lower eyelid. Keratinization of the palpebral conjunctiva is present. Image courtesy of Marcus M. Marcet, MD FACS. https://eyewiki.aao.org/Ectropion#:~:text=There%20are%20four%20main%20types,cicatricial%2C%20mechanical%2C%20and%20paralytic.
Ectropion (or the outward turning) of an eyelid will result in the pink, conjunctival surfaces becoming exposed to room air. This is a normally pink, moist membrane akin to the lining of your mouth. (Imagine how dry and awful your mouth could feel if you left it open all the time, so that the lining would become dry and irritated). That continuous exposure could also allow the normally moist eye membranes to become more like your skin and less like the thin, smooth, moist membrane that it should always be (this transformation to a skin-like surface is called keratinization). Skin is a rougher, drier covering – so that rough, skin-like surface could end up rubbing against the delicate cornea (the clear “window” of the eye). Corneas do not feel good, nor do they see well when they are continually scratched. The out-turning of the lid can also make it hard for the cornea to become refreshed with tears when you blink, as the tears may roll over the out-turned lid rather than be pumped up over the eye with a blink (more on this below).
To fix an Ectropion, it is important to determine the cause, and surgery may often be required. Avoiding sun damage is usually as simple as wearing sunglasses and using sunblock. Not excessively rubbing the eyes helps avoid the stretching and weakening of the ligaments. If the cause is “floppiness” (see my upcoming post on floppy eyelids and related sleep apnea), then dealing with the sleep apnea can often help stop further floppiness (and may help repair it over time).
When there is ectropion-related exposure, then having plenty of healthful tears will help to limit the dryness, exposure and scratching that is otherwise common. However, it is hard to have the good blinks which are beneficial to making good tears until the lid position and “blink mechanics” are restored – so fixing the lid is often required to allow proper tear production and distribution. Caught early, a small operation like “ignipuncture” (tiny burns applied in a precise way) can help support and turn the lid back to a normal position with the tightening from healing, caused by this procedure. In-office treatments can be offered using radio frequency technology, for that purpose. If an ectropion progresses, then more surgery is generally required and may involve tightening the lid by surgically shortening it - and then “resuspending it” to the natural “hammock attachment sites.” Surgically “re-draping” the muscles can help rebalance the “hammock,” when just re-suspending it isn’t enough.
Even a small out-turning of the inner corner of the eyelid can present a problem, as it can put the opening to the tear duct beyond the pool of old tears that would usually be drawn into the tear duct with a blink. This normal event is what allows proper turnover of the tears on the eye (remember the old, dirty, used-up tear has to be replaced by the fresh, healthy tear every time you blink. The old tear goes down the tear duct and ends up in the back part of the nose - but only if it can find its way to the opening of that tear duct. The “windshield wiper” function of the lid is also what brings the healthy tears up to replace the old tears - and a turned out lid can ruin the “wiper” function and interfere with even that level of proper “circulation.”)
The opening to the tear duct is called the punctum and once it drifts away from the eye, we call it a “punctal ectropion” and the effect can cause tears to bypass the normal tear duct and track down the inner corner of the lid. This will cause tears to run down the cheek, making it look like you’re emotionally crying. This type of tearing can also occur from blockages within the tear duct system, from loose or excess conjunctival membranes blocking the surface of the tear duct or acting as a “water slide,” diverting tears (from conjunctivochalasis - see my earlier postings on this, beginning here: https://www.eyethera.com/blog/what-is-conjunctival-chalasis-cch-and-why-should-i-care ) or from excessive “reflex tearing” caused by excessive dryness (see my post on overly salty tears and “reflex tearing” here: https://www.eyethera.com/blog/overly-salty-tears ) - so your doctor should check to find the cause of abnormal tearing and then treat it accordingly.
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463